Cystic Acne Relief With Kenalog Injections
Unicameral bone cysts —Comparison between surgical and steroid injection treatmentZeige alle Jahrgänge und Ausgaben. Die Anzeige der Jahrgänge kann aufgrund fehlender Aufsatznachweise unvollständig oder lückenhaft sein, obwohl die Zeitschrift komplett in der Steroid injection on cyst verfügbar ist. Browsing-Einstiege Zeitschriften durchsuchen Konferenzen durchsuchen. Semesterapparate Semesterapparat einrichten Formular Semesterapparat einrichten. Presse und Wteroid Pressemitteilungen Pressearchiv. Karriere und Ausbildung Chancengleichheit Stellenangebote Ausbildung.
Discal cysts are defined as intraspinal, extradural cysts with a distinct communication with the corresponding intervertebral disc. These lesions, which are extremely rare among spinal pathologies and usually occur in the third or fourth decade of life, are more prevalent in male patients with a higher occurrence reported in Asian populations.
Nevertheless, reliable evidence about epidemiology and natural history of this pathological entity is not available, further accentuated by the lack of large series with longer term follow-up. Indeed, the definition of these lesions was a relatively recent one, with its formal description provided by Chiba et al in A review of the literature revealed 37 previously published articles on lumbar discal cysts; all reported cases demonstrate that the clinical picture determined by discal cysts is indistinguishable from other causes of low back pain and radiculopathy such as conventional disc herniations.
Although early reports had recommended discography for presurgical diagnosis of discal cysts, advances in imaging techniques, particularly in magnetic resonance imaging MRI , made the diagnosis easier and noninvasive. In this article, we provide a brief literature review regarding the management of lumbar discal cysts and describe a new case. A year-old man presented with a 3-month history of severe back pain, radiating down to his right leg, with associated paraesthesias in the ipsilateral L3 and L4 dermatomes.
The right knee jerk was absent. The patient's examination was otherwise unremarkable. Lumbar spine X-rays showed no deformities or overt degenerative changes.
Lumbar MRI revealed a spherical, intraspinal, extradural cystic mass adjacent to the right dorsolateral side of the L3—L4 disc and extending into the ipsilateral recess. The cyst appeared hypointense on T1-weighted images and hyperintense on T2-weighted ones.
After gadolinium infusion, the cyst wall was homogeneously enhanced. The L3—L4 disc showed clear signs of degeneration [ Fig. On computed tomography CT , the lesion appeared as a hypodense, slightly hyperdense, round mass sited in the right lateral recess, which appeared enlarged, causing scalloping of the posterior vertebral body's surface [ Fig. In surgery, we performed a partial, right-sided L3 and L4 laminectomy and medial facetectomy under microscopic magnification.
After incising the ligamentum flavum, a thin-walled cystic lesion, containing gelatinous material, was observed on the right ventrolateral surface of the dural sac [ Fig. During dissection maneuvers, the cyst was fenestrated and a citrine gel—like material emerged. The cyst was completely removed by sectioning its connection with the annulus fibrosus.
A connection between the cyst and the L3—L4 intervertebral disc, through a round defect in the annulus fibrosus, was identified. Histopathological examination of the cyst revealed dense fibrous connective tissue, with hemosiderin deposits, without lining cell layers and disc material. No perioperative complications were observed, and the patient was discharged with complete relief of complaints.
A 6-month follow-up MRI scan showed the complete resection of the cyst, a good height of the degenerated disc, and a satisfactory decompression of nervous structures [ Fig. At the 2-year follow-up, the patient remains asymptomatic. In the second half of the s, some cases of cysts within the spinal canal that communicated with the intervertebral disc were reported in the Japanese literature.
In , Toyama et al first highlighted the communication between such cystic lesions and the intervertebral disc. Two years later, Chiba et al[ 1 ] proposed that disc cysts should encounter the following characteristics: Despite the possibility of CT scans showing indirect signs of long-standing disc cysts, such as bony scalloping in the vertebral body or the lateral recess, imaging of discal cysts is preferably based on MRI.
Lee et al[ 6 ] described the MRI features of discal cysts: Such features were observed in the case we report, where further invasive radiological imaging was not deemed appropriate. This finding is diagnostic for discal cysts and has not been demonstrated in lumbar disc herniations or other spinal cysts. Histologically, the main difference between discal cysts and other intraspinal cysts, such as synovial cysts of the facet joints or cysts of the ligamentum flavum, is based on the absence of lining cells in the discal cyst's wall.
The etiology and pathogenesis of discal cysts remain unclear. Currently, two hypotheses have been suggested. Toyama et al[ 12 ] and Chiba et al[ 1 ] proposed that an epidural hematoma is initially formed by hemorrhage from the epidural venous plexus, resulting from an underlying disc injury. The discal cyst then develops out of incomplete hematoma resorption. This theory was supported by the reports that most of the cysts studied contained hemosiderin deposits. However, this hypothesis cannot explain the linking stalk between the intervertebral disc and the cyst through an annular defect.
Kono et al[ 13 ] proposed a mechanical stress—induced focal degeneration of the posterior disc wall, followed by fluid collection, reactive pseudomembrane formation around the fluid collection, and subsequent development of the discal cyst. The histologically confirmed presence of fibrous connective tissue without synovial lining cells, imaging and intraoperative findings of an annular fissure, and a communicating stalk between the intervertebral disc and the cyst support the latter hypothesis.
The reported mean age at diagnosis is The existing literature about discal cysts is summarized in [ Table 1 ]. Overall, patients have been reported. According to the existing literature,[ 7 ] [ 16 ] the majority of patients are males, with few reported female patients; moreover, a large number of discal cyst cases are reported in the Asian population.
The sex-related incidence rate could suggest a hormonal influence in the pathogenesis of discal cysts. The predominant incidence in Asia may be related to lifestyle, habits, or genetic factors. However, further demographic and genetic studies are required to explain such racial distribution. Some reports described medical treatment as the initial management of discal cysts in cases with tolerable pain and without neurologic deficits. Of these, spontaneous regression occurred in three patients Conversely, Chou et al[ 17 ] reported the spontaneous regression of a discal cyst 5 months after a routine steroid epidural injection and selective nerve root block.
The real effectiveness and the mechanism of steroid injection are still unclear. Moreover, the percutaneous injection procedures are invasive and not totally free from risks.
An alternative option for management of discal cysts was proposed by Koga et al[ 18 ] in They reported the successful management of a lumbar discal cyst by percutaneous CT-guided aspiration and steroid injection. Similarly, Kang et al[ 19 ] applied this technique, without using steroid injection, on eight patients, reporting a good or excellent outcome in seven cases.
Such a circumstance, together with the relapsing clinical symptoms, may support the need for a more radical management, that is, the surgical resection of the cyst. Surgical techniques in the treatment of discal cysts include endoscopic and microscopic resection of the cyst.
This literature review discovered that most cases of discal cysts 69 cases were successfully managed by microscopic resection of the cyst. This is a simple technique with no reported related morbidity or mortality, good clinical results, and low rate of cyst recurrence.
Coscia and Broshears[ 20 ] presented two more cases of discal cysts, also successfully treated surgically. More recently, Nabeta et al[ 2 ] and Kim and Lee[ 21 ] reported other small series of cases of lumbar discal cysts treated by microsurgical resection with good outcomes. Interestingly, Lee et al[ 6 ] reported at 1-year follow-up one case of recurrence out of nine patients with discal cysts surgically resected.
An endoscopic approach has also been proposed as another treatment modality of discal cysts. Ishii et al, in , first proposed such therapeutic option. Overall, 19 patients who underwent endoscopic treatment were found in the literature. One of these, in Ha's series, experienced the persistence of symptoms. It remains unclear whether or not the corresponding intervertebral disc in connection with the cyst should be excised.
Even in cases with uncertain preoperative differential diagnosis, surgery has to be performed to relieve the compression of neural structures, regardless of its origin. In such cases, the intraoperative finding of an obvious connection between the corresponding intervertebral disc and the cystic lesion is useful and important to differentiate discal cysts from other intraspinal cysts.
However, this point also remains controversial as highlighted by Marshman, who critically commented on the pathogenetic hypotheses and anatomopathological features of discal cysts as distinct pathological entities. In the present case, we preferred to excise the discal cyst and also perform a microdiscectomy, as we thought that a more radical excision might decrease the risk of recurrence.
At the 2-year follow-up, the patient remains asymptomatic with no MRI evidence of discal cyst recurrence. It is difficult to draw evidences on the best treatment of discal cysts as the natural history and the long-term prognosis remain unclear.
More cases with longer follow-up are needed to provide therapeutic guidelines. The thorough analysis of previously reported data on the management of discal cysts suggests that MRI should be considered as the preferred diagnostic tool; discography, followed by CT scan, is essential to definitely demonstrate a communication between the cyst and the disc space.
Traditional myelography and CT myelography play a marginal role in the diagnosis, confirming the extradural location of the cyst, but these studies do not add relevant information relative to MRI scans.
In conclusion, we report a new case of lumbar discal cysts with symptoms and findings resembling a typical lumbar disc herniation, which was successfully treated by microsurgical resection. Although it is a rare pathological entity, lumbar discal cysts should be considered in the differential diagnosis of low back pain and lower limb weakness.
We submit that the operative indications and management strategy of discal cysts are likely to be similar to those applied to lumbar disc herniations; moreover, microsurgical resection appears to be the best treatment for discal cysts in patients with severe pain and neurological impairment. EBSJ appreciates the detailed case report on intradiscal cysts and the balanced commentary by Dr. These contributions underscore the importance of collecting small series or rare occurrence disorders in a centralized database with an attempt at a consistent treatment protocol to maximize the possibility for scientific insight.
Alternatively, a region like AOSpine Asia-Pacifica might be interested in starting a larger data collection effort given the much higher prevalence of this condition in that particular region. In the case of discal cysts, we really seem to need just about everything: Hopefully, this case report will stimulate creation of a rare case database for these types of disc pathology and raise the awareness of the global AOSpine surgery community to this entity.
Of course, any further thoughts or experiences with the diagnosis or treatment of this pathology are welcome. Evidence-Based Spine-Care Journal ; 05 Ich möchte folgenden Artikel weiterempfehlen.
Ich möchte folgende Zeitschrift weiterempfehlen. Keywords discal cyst - discography - intervertebral disc - intraspinal cyst - lumbar spine. Introduction Discal cysts are defined as intraspinal, extradural cysts with a distinct communication with the corresponding intervertebral disc.
Case Description A year-old man presented with a 3-month history of severe back pain, radiating down to his right leg, with associated paraesthesias in the ipsilateral L3 and L4 dermatomes. Noticeable is the ring enhancement around the cyst. MRI, magnetic resonance imaging. The fissured annulus fibrosus is visible after resection B. Discussion In the second half of the s, some cases of cysts within the spinal canal that communicated with the intervertebral disc were reported in the Japanese literature.
Total number of cases: Editorial Perspective EBSJ appreciates the detailed case report on intradiscal cysts and the balanced commentary by Dr. Intraspinal cyst communicating with the intervertebral disc in the lumbar spine:
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Campanacci DA, Manfrini M () Unicameral and aneurysmatic bone cysts. levels in unicameral bone cysts reated by intralesional steroid injection. Blood – Frankel SL et al () Steroid injection of a unicameral bone cyst of the calcaneus: literature review and two case reports. J Foot Surg. Nail changes and association ofosteoarthritis in digital myxoid cyst. Arch Dermatol ; –  Epstein E. Steroid injection of myxoid finger cysts.